Meadowbrook Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bolingbrook, Illinois.
- Location
- 431 West Remington Boulevard, Bolingbrook, Illinois 60440
- CMS Provider Number
- 145710
- Inspections on file
- 33
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Meadowbrook Manor during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and handling, including ice buildup and damaged strip curtains in the walk-in freezer, storage of pots and pans on rust-colored racks, and dietary staff handling food with soiled gloves without changing them or using utensils. These practices were inconsistent with facility policies and affected all residents receiving meals.
Several residents dependent on staff for ADLs did not receive timely incontinence care or adequate nail hygiene. One resident was left in a saturated incontinence brief and soiled clothing for hours, while others had long, dirty fingernails despite care plans requiring staff assistance. Staff interviews confirmed these care omissions, and facility policy required such assistance.
Surveyors found that several medications, including inhalers, eye drops, and unopened insulin, were either not dated upon opening or improperly stored outside of refrigeration. Nursing staff confirmed that pharmacy guidelines require dating and proper storage of these medications, but these procedures were not followed for multiple residents.
Five residents on pureed diets were served pureed chili in smaller portions than planned, as staff used a #8 scoop instead of the required #6 scoop according to the menu and facility policy. The error was confirmed by both the Food Service Director and the Dietitian, who emphasized the importance of following planned menus to meet nutritional needs.
Staff failed to consistently follow Enhanced Barrier Precautions, including wearing gowns and performing hand hygiene, during high-contact care activities such as wound care, g-tube care, and incontinence care for multiple residents with wounds, indwelling devices, or incontinence. Despite clear facility policies and signage, nurses and CNAs were observed providing care without required PPE and not changing gloves or sanitizing hands between dirty and clean tasks.
Several residents with complex medical histories were not properly educated or offered influenza and pneumococcal vaccines as required by facility policy and CDC guidelines. In some cases, consent was obtained but the vaccine was not administered, and in others, there was no documentation of education or offer of vaccination. Staff interviews confirmed lapses in following immunization protocols and documentation requirements.
A resident with chronic kidney disease and diabetes had a physician order for daily weights related to dialysis, but nursing staff did not document daily weights as required. Only weights from the dialysis provider on treatment days and a summary were available, and the DON confirmed that no other daily weights were recorded, despite facility policy requiring physician orders to be followed.
A resident with multiple complex medical conditions developed a worsening pressure injury after refusing recommended interventions such as repositioning and a low air loss mattress. Facility staff did not document that the resident was educated about the need for these interventions or the consequences of refusal, and the care plan did not initially address the resident's refusals. The wound continued to deteriorate, and required interventions were not adequately explained or documented as refused with proper education.
Two residents experienced deficiencies in care: one was served regular ice cream despite orders for a pureed, nectar thickened liquid diet due to oropharyngeal dysphagia, and another, identified as high fall risk, had their wheelchair left at bedside contrary to care plan instructions, leading to unsupervised transfer attempts. Staff interviews revealed lack of awareness regarding dietary restrictions and fall prevention interventions, and facility policies requiring adherence to physician orders and individualized fall precautions were not followed.
A resident with dementia and cognitive impairment was provided with bed rails without a documented assessment for entrapment risk, as required by facility policy. Staff relied on a consent form instead of a specific risk assessment, and interviews confirmed that no separate evaluation was performed prior to bed rail use, despite the resident's confusion and poor safety awareness.
Staff failed to follow physician orders and facility policy during medication administration for two residents, including crushing multiple medications together instead of separately and administering incorrect dosages and intervals for nasal spray and inhalers. These actions resulted in a medication error rate significantly above acceptable standards.
A resident with multiple chronic conditions experienced ongoing tooth pain and significant dental decay, repeatedly informing staff of the issue over several months. Despite these reports, the resident was not scheduled for dental care, had not seen a dentist since admission, and only received antibiotics for decaying teeth on the day of the survey. Facility policy required routine dental care, but this was not provided.
A resident with multiple serious health conditions was not provided education about or offered the COVID-19 vaccine, and there was no documentation of any such education or offer in the medical record. Staff interviews confirmed that the process for immunization education and offering had not been completed for this resident, despite facility policy requiring it.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify the individuals involved or the exact hazards present.
Two residents admitted for hospice respite care did not receive their prescribed medications due to failures in medication reconciliation, communication, and order entry by nursing staff. Despite having medication lists and the medications present in residents' belongings, staff did not locate, clarify, or order the necessary drugs, resulting in one resident experiencing a seizure and hospitalization, and another experiencing unmanaged symptoms and discomfort.
A resident admitted for respite care did not receive prescribed anticonvulsant and insulin medications due to staff failing to locate, administer, or order the drugs, despite having the medication list and the medications being present in the resident's belongings. The resident subsequently experienced a seizure and required hospitalization.
A resident admitted for hospice respite care received unnecessary medications because facility staff did not clarify which medication list to follow when presented with conflicting orders from the hospital and hospice provider. The resident was given several medications not included in the hospice regimen, and staff failed to communicate with the hospice provider or physician to resolve the discrepancy, contrary to facility policy.
Several residents who were dependent on staff for ADLs did not receive scheduled showers, shaving, or fingernail care, and there was a lack of documentation for provided care or refusals. Observations included residents with long fingernails, beard growth, and poor hygiene, while staff interviews revealed inconsistent documentation and confusion between bed baths and showers.
Two residents were sexually abused by a housekeeper in an LTC facility. One resident reported the assault, describing inappropriate touching by a tall black man wearing a mask, identified as a housekeeper. The facility's investigation revealed the housekeeper admitted to being in the room and having physical contact with a resident. Despite consistent accounts from the residents, the facility initially did not substantiate the allegations, leading to an Immediate Jeopardy situation.
Two residents reported being sexually assaulted by a housekeeper, but the facility failed to thoroughly investigate the allegations. Despite consistent accounts from the residents and video footage showing unusual behavior by the housekeeper, the facility initially did not substantiate the claims. The facility's inadequate response potentially affected all residents, as the abuse policy was not properly followed.
The facility failed to provide timely assistance with ADLs for several residents, including one who waited over an hour for colostomy care and another who remained in bed for nearly two hours after requesting help. Residents reported delays in receiving assistance with toileting, grooming, and pain management, contrary to the facility's ADL policy.
The facility experienced significant staffing shortages, leading to delayed care for residents. A resident who was dependent on staff for daily activities remained in bed for nearly two hours after requesting assistance. Another resident waited almost an hour for a colostomy bag change, while others reported delays in receiving pain medication and assistance with personal hygiene. Staff confirmed frequent shortages, with CNAs often assigned more residents than usual.
A facility failed to change a resident's rectal tube collection bag daily as per manufacturer guidelines, instead emptying and reusing it, which was against instructions. Staff, including RNs and CNAs, were unaware of the proper procedure, leading to potential risks of infection. The ADON acknowledged the need for daily changes, but the practice of reusing the bag continued.
The facility failed to administer wound care treatments as ordered for two residents with pressure ulcers. One resident with an unstageable pressure ulcer did not receive the prescribed Medihoney gel treatment on multiple occasions, while another resident with a Stage 3 pressure ulcer on the sacrum missed several treatments. The facility's wound care nurse and physician confirmed the expectation for staff to follow all wound care orders, but documentation was lacking, indicating non-compliance with the facility's medication administration policy.
A resident's family repeatedly raised concerns about inadequate incontinence care, leading to wounds on the resident's scrotum. Despite complaints, the facility failed to investigate or resolve the issue, leaving the resident soiled for extended periods. The facility's grievance policy was not followed, as no investigation or corrective actions were documented.
Two residents with severe cognitive impairments were involved in a physical altercation after one entered the other's room, leading to minor injuries. The facility's initial report to IDPH was inaccurate, and the incident was not substantiated as abuse due to the residents' cognitive conditions.
A facility failed to conduct a thorough investigation following a physical altercation between two residents with severe cognitive impairments. The incident involved one resident entering another's room, leading to a confrontation. The facility's report to IDPH was inaccurate, and the investigation lacked documentation of interviews with potential witnesses, contrary to the facility's abuse prevention policy.
A resident with moderate cognitive impairment and incontinence was left without timely incontinence care for several hours, resulting in inadequate cleaning and family concerns about a scrotal wound. The resident's care plan, which included regular peri care and repositioning, was not followed during the observed period.
A facility failed to assess a resident for elopement risk within 24 hours of admission and did not implement interventions despite a high-risk score. The resident, with multiple diagnoses including dementia, exhibited exit-seeking behavior but was not wearing an alarm or a yellow bracelet. The DON was unaware of the behavior, and the facility's identification method at the reception desk did not include the resident's information.
The facility failed to maintain the dishwashing machine at the required temperatures for proper sanitization, affecting all residents receiving food from the kitchen. Observations showed fluctuating temperatures below the required 180 degrees Fahrenheit for the final rinse, and test strips did not indicate proper sanitization. The facility's policy requires specific temperature thresholds, which were not met during the inspection.
The facility failed to hold quarterly QAPI meetings and ensure required member attendance, missing a meeting during a COVID outbreak affecting residents and staff. The Medical Director was absent from a subsequent meeting, indicating a lapse in adherence to the facility's QAPI policy.
The facility did not offer the COVID-19 vaccine to its 250 residents and staff, despite a previous outbreak. Several residents had not been offered further vaccinations since October 2022, and there was no documentation of vaccine offers or education in 2023 and 2024. The IP stated they educate about the vaccine but do not offer it, encouraging individuals to use their insurance instead. Maintenance staff confirmed they had not been offered the vaccine in two years.
The facility failed to provide written notification to residents or their representatives about the termination of Medicare Part A services. Verbal notices were given, but there was no documentation of written notices, affecting four residents. The facility's process involved phone notifications without certified written follow-up.
The facility failed to properly label, date, and store medications, leading to deficiencies in medication management. Observations revealed that medications were not dated upon opening, expired medications were not removed, and some medications lacked proper pharmacy labeling. Insulin storage practices were also not followed, with unused insulin pens stored in medication carts instead of being refrigerated. These issues were observed across multiple residents, indicating a systemic problem in the facility's adherence to medication protocols.
The facility failed to use the correct serving scoop sizes for mechanical soft and pureed beef cubed steak, affecting 10 residents. The cook used incorrect scoop sizes, contrary to the facility's policy and menu spreadsheet, which led to improper portion sizes being served. The dietitian confirmed the need to follow the approved menu for nutritional accuracy.
A long-term care facility was found deficient in infection control practices, including improper hand hygiene, failure to use PPE, and incorrect handling of urinary catheters. Staff did not follow protocols for hand hygiene and PPE use, and catheter drainage bags were observed on the floor, contrary to facility policy. Additionally, a CNA failed to use a gown as required by Enhanced Barrier Precaution protocol for a resident with a history of ESBL.
A resident's healthcare information was exposed when a laptop displaying their MAR was left unattended on a medication cart in a hallway. The screen was visible to another resident and staff members, including a Laundry Aide and a Restorative Aide, for about ten minutes. The LPN responsible admitted to not knowing how to secure the screen, indicating a lack of training. The resident had multiple diagnoses and was moderately cognitively impaired.
The facility failed to assist three residents with activities of daily living (ADLs) and meal support. One resident with dementia was left with facial hair despite needing grooming assistance. Another resident had significant oral hygiene issues, including tartar buildup, and was not provided with necessary grooming. A third resident, cognitively impaired, was left to eat with bare hands without staff assistance, contrary to the facility's policy. These deficiencies highlight a lack of adherence to care plans and facility policies.
A resident with a stage 4 pressure ulcer did not receive adequate wound care, as observed by surveyors. The resident's dressing was heavily saturated and almost detached, despite requiring daily and as-needed changes. The Director of Nursing confirmed the need for frequent dressing changes due to the resident's incontinence. The resident's care plan highlighted a high risk for skin breakdown, but necessary interventions were not followed, resulting in the deficiency.
The facility failed to timely address pharmacist recommendations for two residents, leading to delays in medication adjustments for psychotropic drugs. The DON admitted to placing recommendations in a mailbox without a specific follow-up timeframe, and the Administrator emphasized the need for immediate communication of such recommendations.
Deficient Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices within the facility's kitchen, affecting 225 residents who receive meals prepared on-site. During an initial tour, significant ice buildup was found on the floor and PVC strip curtains of the walk-in freezer, with ice crystals forming on food items such as individual servings of ice cream and nutrition treats. The PVC strip curtains were torn and broken, and the Food Service Director confirmed that the freezer door did not close properly, contributing to the ice accumulation. Additionally, pots and pans were stored inverted on racks that showed brownish discoloration resembling rust, and the Food Service Director acknowledged that the racks were old and needed replacement. During meal service, dietary staff were observed plating food while wearing gloves soiled with food residue, and continued to handle multiple food items without changing gloves or using utensils as required. The Food Service Director confirmed that staff should use tongs and change gloves after washing hands. The facility's policies require monthly inspections of refrigerators and freezers for maintenance issues and prohibit bare hand contact with food, mandating glove changes between tasks. The Dietitian also stated that rusted racks should not be used for pot and pan storage due to the risk of contamination, and that utensils should be used for serving food.
Failure to Provide Timely Incontinence and Nail Care Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically incontinence care and nail care, for several residents who were dependent on staff for these needs. One resident with hemiplegia, aphasia, and dementia was observed sitting in the dining room for nearly three hours without being checked or changed, despite care plans requiring staff to check and change incontinence briefs every two hours. When eventually attended to, the resident's brief, clothing, and mechanical lift sling were saturated with urine, and staff confirmed that care should have been provided sooner. Other residents with severe cognitive impairment, central cord syndrome, and dementia were observed with long, jagged fingernails containing black substances underneath. These residents required maximal or total assistance with personal hygiene and grooming, as documented in their care plans. Despite this, their fingernails remained untrimmed and unclean over consecutive days, and some residents verbally expressed their desire for staff to trim and clean their nails. Staff interviews confirmed that grooming, including nail care, was the responsibility of the CNAs and should be performed as needed. The facility's own ADL policy required staff to provide appropriate care and services to maintain residents' hygiene and grooming, including nail care and toileting, for those unable to perform these tasks independently. Observations and interviews demonstrated that staff did not consistently follow these policies, resulting in residents not receiving timely incontinence care or adequate assistance with nail hygiene.
Failure to Label and Store Medications According to Pharmacy Guidelines
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications for seven residents during a medication cart inspection. Specifically, multiple inhalers, eye drops, and insulin pens were found either open and not dated or stored incorrectly. For example, two inhalers and several eye drop bottles were open without being dated, despite pharmacy recommendations and stickers indicating that these medications should be dated upon opening to determine expiration. Additionally, unopened insulin pens were stored at room temperature in the medication cart instead of being refrigerated as required by pharmacy instructions. Interviews with nursing staff and the Assistant Director of Nursing confirmed that staff are expected to follow pharmacy guidelines for labeling and storing medications, including dating upon opening and refrigerating unopened insulin. The facility's pharmacy administration guide also specifies that eye medications with accelerated expiration dates must be dated and initialed when opened, and that manufacturer instructions or facility policy should be followed for all medications. These failures were identified for seven residents reviewed for medication storage and labeling.
Incorrect Portion Sizes Served for Pureed Diets
Penalty
Summary
The facility failed to serve the correct portion sizes of pureed chili as specified in the planned menu for five residents on pureed diets. Observations during the lunch meal service showed that the cook used a #8 scoop, which provides 1/2 cup, instead of the required #6 scoop, which provides 2/3 cup, as indicated on the daily menu spreadsheet and the facility's portion control chart. The Food Service Director confirmed that the wrong scoop was used, and the Dietitian stated that the menu should be followed to ensure residents receive the appropriate nutrients. Facility policy requires that food be served in portions indicated on the cycle menu and that serving utensils be checked prior to meal service to ensure accuracy. The affected residents were all on pureed diets at the time of the deficiency.
Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Surveyors identified multiple failures by facility staff to follow standard infection control practices, specifically regarding Enhanced Barrier Precautions (EBP), hand hygiene, and glove use during care and medication administration. Several residents with conditions such as gastrostomy tubes, indwelling urinary catheters, pressure ulcers, wounds, and incontinence were observed to be on EBP, as indicated by signage and care plans. Despite these precautions, staff members, including nurses and CNAs, were repeatedly observed providing high-contact care activities—such as wound care, g-tube care, and incontinence care—without donning required gowns, and in some cases, without performing proper hand hygiene before or after care tasks. For example, staff provided g-tube care and administered medications to residents on EBP without wearing gowns, and wound care was performed without the use of gowns as required by facility policy. In several instances, staff wore gloves but failed to change them or perform hand hygiene between dirty and clean care tasks, such as during incontinence care and the application of ointments. These lapses occurred despite clear EBP signage and care plan instructions specifying the need for gloves and gowns during high-contact activities and the necessity of hand hygiene before entering and after leaving resident rooms. The facility's own EBP policy, last reviewed in April 2025, mandates the use of gowns and gloves for high-contact care activities for residents at increased risk for multidrug-resistant organisms (MDROs), including those with wounds, indwelling devices, or requiring extensive hands-on care. Staff interviews confirmed awareness of these requirements, yet observations revealed consistent non-compliance with established protocols, including failure to wear appropriate PPE and to perform hand hygiene at critical points during resident care.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations per Policy
Penalty
Summary
The facility failed to follow its own policies and CDC guidelines regarding the offering and administration of influenza and pneumococcal vaccines to residents. Specifically, documentation was lacking to show that several residents or their representatives were provided education and offered these vaccines as required. For example, one resident with multiple diagnoses, including dementia and heart disease, had no documentation of being offered or educated about either the influenza or pneumococcal vaccine during the relevant period. Another resident with chronic respiratory conditions had consent for the pneumococcal vaccine documented, but the vaccine was not administered as of the survey date. Additionally, a resident with a history of atherosclerosis and dementia had documentation of a prior pneumococcal vaccine but no evidence of being offered or educated about additional pneumococcal vaccination or the influenza vaccine for the current season. Another resident with multiple chronic conditions, including diabetes and COPD, also lacked documentation of being offered or educated about the pneumococcal vaccine. In each case, the required education, offer, and documentation steps outlined in facility policy and CDC guidance were not followed. Interviews with facility staff confirmed that responsibility for immunizations had recently changed hands, and both the educator and DON acknowledged that residents should have been educated and offered vaccines per policy. The facility's written policies require assessment, education, offer, and documentation of vaccine status and resident decisions, but these steps were not consistently completed or recorded for the affected residents.
Failure to Obtain and Document Daily Weights for Dialysis Resident
Penalty
Summary
A resident with chronic kidney disease, stage 3, type 2 diabetes mellitus with diabetic neuropathy, and polyneuropathy was admitted with a physician order for daily weights to monitor their condition related to dialysis. The facility failed to document that daily weights were obtained as ordered by the physician. The only weights available were those provided by the dialysis provider on dialysis days and a weight summary given to the surveyor. The Director of Nursing confirmed that nursing staff are responsible for weighing residents and are expected to follow physician orders, but acknowledged that no other daily weights were recorded for this resident. The facility's policy requires physician orders to be followed as written, and questions about orders to be clarified with the physician.
Failure to Educate Resident on Consequences of Refusing Pressure Ulcer Care
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, osteoarthritis, hydronephrosis, and acute osteomyelitis, developed a facility-acquired deep tissue injury (DTIP) on the coccyx, which later progressed to a stage 3 pressure ulcer and subsequently to an unstageable pressure injury with significant necrotic tissue. The resident was cognitively intact and required varying levels of assistance with activities of daily living, including being dependent for toileting hygiene and lower body dressing. The resident refused certain interventions, such as repositioning and the use of a low air loss mattress, which were recommended to prevent further wound decline. Despite these refusals, there was no documentation that the resident was educated about the need for these interventions or the consequences of refusing them. The wound care nurse was unable to provide evidence of education regarding the risks associated with refusal of care, and the risk notification was only reviewed with the resident's power of attorney, not the resident themselves. The care plan initially did not address the resident's refusals regarding repositioning until several months after the pressure injury was identified. Wound assessments documented the progression and worsening of the wound, including increased size and necrosis, but did not indicate that education about the consequences of refusal was provided. The facility's policy required ongoing evaluation of the plan of care and reassessment if the patient was not responding to treatment, but there was no evidence that these procedures were followed in relation to educating the resident about the risks of refusing recommended wound care interventions.
Failure to Provide Appropriate Diet Consistency and Fall Prevention Measures
Penalty
Summary
The facility failed to provide appropriate diet consistency and supervision for a resident with oropharyngeal dysphagia and risk for aspiration. The resident was admitted with multiple diagnoses, including hemiplegia, aphasia, dementia, and oropharyngeal dysphagia, and had physician orders and a care plan specifying a pureed, nectar thickened liquid diet. Despite these orders, the resident was observed being served and consuming regular ice cream, a thin liquid, by an activity aide who was unaware of the resident's dietary restrictions and need for supervision. The speech therapist confirmed that the resident required nectar thick liquids and that plain ice cream was not appropriate, as it posed an aspiration risk. Additionally, the facility failed to implement and communicate fall prevention interventions for a resident identified as high risk for falls. This resident had a history of multiple unwitnessed falls and required maximal assistance for mobility and transfers. The care plan and physician orders specified that staff should assist the resident back to bed after meals and remove the wheelchair from bedside for safety. However, observations showed the resident's wheelchair was left next to the bed, allowing the resident to attempt unsupervised transfers. Staff interviews revealed inconsistent understanding of fall risk signage and interventions, with some CNAs unaware of the resident's fall risk status or the meaning of the signage on the doorframe. The facility's policies required adherence to physician orders and individualized fall prevention interventions, including clear communication among staff regarding residents' risks and required precautions. Despite these policies, the observed failures in following dietary orders and fall prevention interventions resulted in deficiencies related to accident hazards and inadequate supervision.
Failure to Assess Entrapment Risk Prior to Bed Rail Installation
Penalty
Summary
The facility failed to assess a resident with cognitive deficits for the risk of entrapment prior to the installation of bed rails. The resident in question had diagnoses including unspecified dementia with behavioral disturbances, depression, bipolar disorder, and other cognitive and behavioral symptoms. The resident was moderately impaired in cognition, required supervision or assistance for bed mobility, and was noted to be impulsive with poor safety awareness. Despite these factors, bed rails were installed without a documented risk assessment for entrapment, as required by facility policy. Staff interviews revealed that the bed rails were used to assist with bed mobility and as a fall risk intervention, but there was no separate risk assessment form completed prior to their use. The consent form signed by the resident's Power of Attorney was incorrectly considered as the risk assessment by staff. Observations showed the resident in bed with half side rails raised on both sides, and staff confirmed that the resident could exit the bed by sliding to the foot of the bed. The resident's care plans documented cognitive impairment, confusion, and poor decision-making abilities, yet the facility did not perform or document a specific entrapment risk assessment before installing the bed rails. The facility's policy required such an assessment, but staff acknowledged that this step was not completed, and the required documentation was not present in the resident's records.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
Surveyors observed that staff failed to follow physician orders and facility policy during medication administration for two residents. In one instance, a nurse administered Allopurinol, Hydralazine, and Torsemide to a resident by crushing all medications together and mixing them with pudding, despite facility policy requiring each medication to be crushed separately and administered individually with food. This action was not in accordance with the facility's Medication Administration Policy and Procedure, which emphasizes safe and prescribed medication administration practices. In another case, a nurse administered Fluticasone Propionate nasal spray by giving two sprays in each nostril, contrary to the physician's order for one spray per nostril once daily. Additionally, the nurse administered two different inhalers (Symbicort and Spiriva) with insufficient intervals between doses and between different inhalers, not adhering to the facility's policy that requires at least one minute between doses of the same inhaler and at least two minutes between different inhalers. These deviations resulted in a medication error rate of 23.07% during the observed medication pass.
Failure to Provide Dental Care for Resident with Painful, Decaying Teeth
Penalty
Summary
A resident with multiple medical diagnoses, including chronic obstructive pulmonary disease, dementia, aphasia, cerebral infarction, chronic systolic heart failure, and type 2 diabetes mellitus, reported ongoing tooth pain and the need to see a dentist. The resident stated that he had informed staff about his dental pain for several months, but no action was taken beyond writing his request on a piece of paper. The resident had not seen a dentist since admission, and staff interviews confirmed that he was not on the facility's dental insurance and had not been scheduled for either in-house or outside dental appointments. Observation revealed the resident had missing lower teeth and a lower left molar with significant decay, covering about 90% of the tooth's surface. On the day of the survey, the resident was started on antibiotics for decaying teeth. The facility's policy required routine dental care, including preventative care and treatment, but this was not provided to the resident, resulting in untreated dental pain and decay.
Failure to Educate and Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine to a resident who had not previously received any COVID-19 immunizations. The resident, who had multiple diagnoses including dementia, malignant neoplasm of the breast, acute embolism and thrombosis of the right femoral vein, and heart disease, was admitted to the facility and as of the date of review, there was no documentation in the electronic medical record indicating that either the resident or their representative had been educated about or offered the COVID-19 vaccine. Interviews with facility staff revealed that responsibility for resident immunizations had recently transitioned from the previous DON to a new educator. The educator confirmed that he had assumed the role only a few weeks prior and that the facility follows CDC guidelines for immunizations. The DON acknowledged that residents should be educated and offered vaccines according to facility policy and CDC guidance, and confirmed that this had not occurred for the resident in question. The facility's policy requires that all eligible individuals be educated and offered the most recent COVID-19 vaccine, but this process was not documented or completed for the resident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Administer and Reconcile Hospice Medications Results in Resident Neglect
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect by not ensuring that medications were obtained and hospice orders were followed for two residents admitted for hospice respite stays. In the first case, a resident with multiple complex diagnoses, including epilepsy and diabetes, was admitted without a clear medication reconciliation process. Despite having the hospice medication list and being informed that the family was to provide medications, nursing staff did not locate the medications in the resident's belongings, did not notify the physician or hospice provider for clarification, and did not order the necessary medications from the pharmacy. As a result, the resident did not receive critical medications, including anticonvulsants and insulin, leading to a witnessed seizure and subsequent hospitalization. In the second case, another resident admitted for hospice respite care also experienced a failure in medication management. The resident arrived with her home medications, and the facility had two conflicting medication lists—one from the emergency room and one from hospice. The facility did not clarify which list to follow with the hospice provider or physician, nor did they ensure that scheduled medications for comfort and symptom management, such as Quetiapine and Ambien, were entered into the electronic medical record or administered. The resident's medications remained untouched in her belongings throughout her stay, and the lack of appropriate medication administration contributed to increased restlessness and discomfort during her end-of-life care. Interviews with staff, family members, and hospice providers confirmed that the necessary medications were either present with the residents or could have been obtained promptly if ordered. The facility's own policies defined neglect as the failure to provide goods and services necessary to avoid physical harm or emotional distress, and staff acknowledged that the residents should have received their medications. The documentation and interviews revealed a lack of communication, failure to follow established procedures, and inadequate assessment and response to the residents' medication needs.
Failure to Administer Prescribed Medications to Hospice Resident
Penalty
Summary
A hospice resident admitted for a respite stay was not administered prescribed anticonvulsant medication (levetiracetam/Keppra) and insulin as indicated in the hospice records and provided by the family. Upon admission, the resident's history and physical, including a medication list, were uploaded to the electronic medical record, but staff failed to ensure the medications were located or administered. Nursing staff did not document attempts to find the resident's home medications, notify the physician or hospice provider about missing medications, or order the necessary medications from the pharmacy, despite having the medication list available. The resident, who had a complex medical history including epilepsy, diabetes, and cognitive impairment, did not receive any of his prescribed medications during his stay. Staff relied on the expectation that the resident's daughter would bring the medications, but when this did not occur, no further action was taken to obtain or administer the required drugs. Communication with the hospice provider and family was attempted, but there was no follow-up to ensure medication administration, and the medications were later found in the resident's belongings after the incident. As a result of not receiving his anticonvulsant medication, the resident experienced a seizure and required hospitalization. Hospital records confirmed the resident had not received his medications for over 36 hours, and both the facility's nurse practitioner and pharmacists confirmed that missing doses of Keppra could result in breakthrough seizures. The facility's own policy required medications to be ordered from the pharmacy if not supplied by the family, but this was not followed.
Failure to Clarify Medication Orders for Hospice Resident
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, diabetes, hypertension, repeated falls, hallucinations, and severe cognitive impairment, was admitted to the facility for a hospice respite stay following a fall at home. Upon admission, there were two separate medication lists for the resident: one from the local hospital emergency room and another from the hospice provider. The facility did not document any communication with the hospice provider to clarify which medication list should be followed during the resident's stay. As a result, the resident received several medications that were not included on the hospice provider's medication list, such as atorvastatin, carvedilol, cholestyramine aspartame, and potassium chloride. These medications were administered over multiple days during the resident's stay, despite the hospice provider's list specifying a different regimen. The facility's Director of Nursing and staff did not contact the physician or hospice provider to resolve the discrepancy between the hospital and hospice medication lists. Interviews with facility staff and the hospice nurse confirmed that the facility should have clarified the appropriate medication regimen, especially since the resident was under hospice care. The facility's own policy required coordination with hospice providers regarding medication information, but this protocol was not followed, leading to the administration of unnecessary medications.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents received showers, shaving, and fingernail care as scheduled and required by their care plans and facility policy. Multiple residents who were dependent on staff for activities of daily living (ADLs) did not receive showers or bed baths according to the established shower schedule, and there was no documentation of refusals or alternative care provided on several occasions. In addition, residents were observed with long fingernails, beard growth, and poor personal hygiene, indicating a lack of assistance with grooming and hygiene tasks. One resident with functional quadriplegia and severe hand contractures was found with long facial hair, long fingernails, and scalp flaking, and reported not receiving preferred showers since being moved to a different room. The resident's care plan required two staff for bathing and regular nail care, but records showed missed showers and no documentation of refusals or alternative care. Another resident, also dependent on staff for ADLs, reported not receiving a shower or bed bath for several days and was unable to access his meal tray without assistance. Documentation for this resident was incomplete, with no record of showers or bed baths provided or refused since admission. Additional residents were observed with long, dirty fingernails and reported not receiving scheduled showers. Care plans for these residents also required regular bathing and grooming, but facility records did not show that these services were provided or refused on multiple scheduled days. The facility's own policies required documentation of showers, refusals, and follow-up actions, but this was not consistently done. Staff interviews confirmed that documentation practices were inconsistent and that some bed baths were recorded as showers, further contributing to the lack of accurate records.
Failure to Protect Residents from Sexual Abuse by Housekeeper
Penalty
Summary
The facility failed to protect residents from sexual abuse, resulting in two residents being sexually abused by a housekeeper. On January 25, 2025, a resident reported being sexually assaulted by a housekeeper, identified as a tall black man wearing a mask, who fondled her breast and touched her vaginal area. The resident, who was cognitively intact, did not immediately report the incident due to shock but later informed her family, who then notified the facility. The resident's roommate was also allegedly assaulted by the same housekeeper, as indicated by her gestures and verbal responses during interviews. The facility's investigation revealed that the housekeeper, V4, admitted to being in the residents' room and having physical contact with one of the residents, which he claimed was to clean a food spill. However, video footage showed V4 entering and exiting the residents' room multiple times without his housekeeping cart, raising concerns about his actions. Despite the residents' consistent accounts of the abuse, the facility initially did not substantiate the allegations, citing a lack of witnesses and the residents' inability to identify the perpetrator due to the mask. The police were notified, and an investigation was initiated, but the facility's response was deemed insufficient, leading to an Immediate Jeopardy situation. The facility's initial removal plan was rejected, and a revised plan was submitted. The facility's policy stated that residents have the right to be free from abuse, yet the failure to protect these residents from sexual abuse by a staff member resulted in a serious deficiency.
Removal Plan
- The facility presented a removal plan to remove the immediacy.
- The facility presented a revised removal plan to remove the immediacy.
Inadequate Investigation of Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of sexual abuse made by two residents, R1 and R2, against a housekeeper, V4. Both residents consistently reported being sexually assaulted by V4, but the facility initially did not substantiate these claims. R2, who was cognitively intact, reported that a tall, black man wearing a mask fondled her breast and touched her vaginal area. R2's roommate, R1, also indicated through gestures and limited verbal communication that she was inappropriately touched in her private area by an African American man. Despite these consistent allegations, the facility's initial investigation did not substantiate the claims, citing a lack of witnesses and other residents not reporting similar incidents. The facility's investigation was inadequate, as it did not thoroughly consider the residents' consistent accounts and the available video footage. The video footage showed V4 entering and exiting R1 and R2's room multiple times without his housekeeping cart, which was unusual behavior for a housekeeper. Additionally, V4 admitted to having physical contact with R2, which should not have occurred as he was not part of the nursing staff. The facility's administrator, V1, conducted interviews with the residents but did not find the allegations substantiated, partly due to a perceived change in R2's mental status and the lack of corroborating witness accounts. The facility's failure to substantiate the allegations and conduct a thorough investigation potentially affected all 237 residents. The facility's abuse policy mandates prompt reporting and thorough investigation of abuse allegations, which was not adequately followed in this case. The facility only sustained R2's allegation after further information was provided by the surveyor, and the police investigation remained ongoing. The facility's initial response and investigation were insufficient, leading to a deficiency in addressing the serious allegations of sexual abuse.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance to residents requiring help with Activities of Daily Living (ADLs), affecting four out of six residents reviewed. One resident, diagnosed with idiopathic progressive neuropathy and other conditions, expressed frustration over not receiving timely assistance to get out of bed, despite being dependent on staff for transfers. The resident had requested help at 9:00 AM but remained in bed until 10:50 AM. Another resident with a colostomy and a history of falls waited over an hour for assistance with changing a full colostomy bag, despite the care plan indicating checks and changes every two hours. Additionally, a resident with cognitive communication deficits and chronic kidney disease reported waiting hours at night for assistance with urinal use, highlighting a staffing issue during night shifts. Another resident, requiring substantial assistance for dressing and bathing, reported waiting an hour for staff to respond to her call light for grooming supplies and pain medication. The facility's policy on ADLs, which mandates providing necessary care to maintain residents' ability to perform daily activities, was not adhered to, resulting in unmet needs for personal hygiene and toileting assistance.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs of its residents, as evidenced by multiple instances of delayed care and unmet needs. Resident 11, who was cognitively intact and dependent on staff for various activities of daily living, expressed frustration over not being assisted out of bed in a timely manner. Despite requesting assistance at 9:00 AM, the resident remained in bed until 10:50 AM. A Certified Nursing Assistant (CNA) confirmed that the facility was frequently short-staffed, with only three CNAs available for 45 residents, many of whom required two staff members for transfers. The staffing coordinator's review of schedules indicated that the facility was short-staffed during approximately one-third of the shifts. Resident 12, who required substantial assistance for toileting hygiene, experienced a significant delay in having her colostomy bag changed, waiting nearly an hour after initially requesting assistance. Similarly, Resident 2 reported waiting hours at night for assistance with using a urinal, and Resident 13 experienced delays in receiving pain medication and grooming supplies. Staff members, including CNAs and a Registered Nurse, acknowledged the frequent staffing shortages, which resulted in CNAs being assigned more residents than usual, further exacerbating the delays in care.
Failure to Change Rectal Tube Collection Bag as Per Guidelines
Penalty
Summary
The facility failed to change a resident's rectal tube collection bag according to manufacturer guidelines, affecting one resident reviewed for quality of care. The resident had a rectal tube inserted, and the waste was collected into a bag that was not changed daily as required. Instead, staff emptied the bag and reattached it, which was against the manufacturer's instructions. The family member of the resident reported that the bag had been on for three days and was leaking, prompting staff to wrap a plastic bag around it. The Assistant Director of Nursing (ADON) acknowledged the need to change the bags daily, but the practice of emptying and reusing the bag continued. Interviews with various staff members, including RNs and CNAs, revealed a lack of awareness and adherence to the manufacturer's guidelines, which specified that the device, including the collection bag, was for single use only. The Clinical Nurse Specialist confirmed that the bags were not designed to be emptied and reused, and doing so could increase the risk of infection or cross-contamination. Despite this, the Director of Nurses (DON) stated that the facility did not have a specific policy for rectal tubes and would follow the manufacturer guidelines, which were not being adhered to in practice.
Failure to Administer Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the physician for two residents, R1 and R5, who were reviewed for pressure ulcer treatments. R1, who has multiple complex medical conditions including an unstageable pressure ulcer, did not receive the prescribed Medihoney gel treatment on several occasions as documented in the Electronic Medical Record (EMR). The treatment was not administered on specific dates in September and October 2024, as required by the physician's order. Similarly, R5, who has a Stage 3 pressure ulcer on the sacrum and is dependent on staff for all Activities of Daily Living (ADLs), did not receive the prescribed Medihoney wound and burn dressing treatment on several dates in November 2024. The facility's wound care nurse and physician confirmed the expectation that nursing staff should follow all wound care orders. However, there was no documentation to show that the treatments were administered as ordered, indicating a failure in adhering to the facility's policy on administering medications and treatments.
Failure to Investigate and Resolve Grievance Regarding Incontinence Care
Penalty
Summary
The facility failed to adhere to its grievance policy by not fully investigating and resolving a grievance raised by the family of a resident, identified as R7. The family frequently found R7 soiled with urine or stool, leading to wounds on his scrotum. Despite repeated complaints to the former administrator and other staff, the issue persisted. On October 8, 2024, during a continuous observation period, R7 was left unattended in a high-back wheelchair without incontinence care for several hours, confirming the family's concerns. R7, who has multiple diagnoses including vascular dementia and is dependent on staff for all activities of daily living, was observed to have moderate cognitive impairment and is always incontinent of bowel and bladder. The family's grievances, documented on multiple occasions, highlighted the lack of timely incontinence care, which was not addressed adequately by the facility. The facility's records show that grievances were acknowledged but not thoroughly investigated or resolved, as required by their policy. The facility's grievance policy mandates a comprehensive investigation of complaints, including gathering accounts from witnesses and involved parties, and recommending corrective actions. However, the facility did not document any investigation or corrective measures for the grievances related to R7's care. The Director of Nursing believed the grievance was resolved by providing immediate care, but there was no documentation of an investigation to prevent recurrence, indicating a failure to comply with the facility's grievance policy.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents with severe cognitive impairments. The incident occurred when one resident entered another's room, leading to a physical altercation. Both residents sustained minor injuries, including bruising and skin tears. The facility's initial and final reports to the Illinois Department of Public Health (IDPH) documented the incident, noting that both residents were assessed and monitored following the altercation. The facility's Director of Nursing later clarified that the initial report was inaccurate, as it was the resident who entered the room that initiated the altercation by going through the other resident's belongings. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite the incident, the facility concluded that abuse could not be substantiated due to the residents' cognitive impairments.
Incomplete Investigation of Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough abuse investigation following a physical altercation between two residents, R4 and R5, both of whom have severe cognitive impairments. The incident occurred when R5 entered R4's room and began going through R4's belongings, leading to a physical confrontation. Staff intervened and separated the residents, and both were assessed for injuries. However, the facility's final report to the Illinois Department of Public Health (IDPH) was inaccurate, as it did not reflect the true nature of the incident. The facility's investigation was incomplete, as it lacked documentation of interviews with potential witnesses, including staff and other residents, to determine if physical abuse could be substantiated. The Director of Nursing (DON) acknowledged the inaccuracies in the final report and the failure to follow the facility's policy for conducting a thorough investigation. The policy requires interviewing all persons who may have knowledge of the incident, including witnesses and staff, and maintaining records of the investigation. The facility's policy on abuse prevention and investigation outlines the process for identifying, assessing, and protecting residents from abuse. Despite this, the investigation into the altercation between R4 and R5 did not adhere to these guidelines, resulting in an unsubstantiated conclusion due to the residents' cognitive impairments. The lack of a comprehensive investigation and accurate reporting to IDPH highlights the deficiency in the facility's handling of the incident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who is dependent on staff for all activities of daily living, including toilet hygiene. On October 8, 2024, a resident was observed from 8:47 AM to 11:15 AM sitting in a high back wheelchair in the dining room without any staff checking or providing incontinence care. The resident, who has moderate cognitive impairment and is always incontinent of bowel and bladder, was not attended to for incontinence care during this period. The CNA assigned to the resident admitted to not having changed the resident's incontinence brief since at least 7:00 AM due to being busy with other residents. When the Nursing Assistant Supervisor and another CNA finally attended to the resident at 11:29 AM, they found the incontinence brief slightly damp with urine and a brown substance with a strong odor in the groin area, indicating inadequate previous cleaning. The resident's family expressed ongoing concerns about the resident's cleanliness and the presence of a wound on the scrotum, which they feared could worsen. The resident's care plan, initiated in April 2024, included interventions for peri care after each incontinent episode and repositioning every two hours, which were not adhered to during the observed period.
Failure to Assess and Mitigate Elopement Risk
Penalty
Summary
The facility failed to follow its policy to assess a resident for elopement risk within the first 24 hours of admission and implement necessary interventions to prevent elopement. The resident in question, identified as R1, was admitted with multiple diagnoses including dementia and moderate cognitive impairment, which necessitated an elopement risk assessment. However, the facility did not have documentation to show that this assessment was completed within the required timeframe. Furthermore, after an eventual assessment indicated a high risk for elopement, no documented interventions were put in place to mitigate this risk. Observations and interviews revealed that R1 exhibited exit-seeking behavior, attempting to use the elevator unsupervised, yet was not wearing any alarm device or a yellow bracelet to indicate elopement risk. The Director of Nursing (DON) was unaware of R1's exit-seeking behavior, indicating a breakdown in communication. Additionally, the facility's method of identifying elopement risks at the reception desk did not include R1's information, further highlighting the lack of proper implementation of the facility's elopement prevention policy.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dishwashing machine at the required temperatures to properly sanitize dishes, affecting all 245 residents who receive food prepared in the facility kitchen. During an observation, a dietary aide was seen operating the dishwashing machine, with temperatures fluctuating between 160-165 degrees Fahrenheit for the wash cycle, 160-163 degrees Fahrenheit for the rinse cycle, and 150-170 degrees Fahrenheit for the final rinse. The test strips used to verify sanitization showed dark brown and tan colors, indicating that the proper sanitizing temperature was not reached. The Food Service Director and Director of Culinary Services confirmed that the temperature gauge should read 180 degrees Fahrenheit and the test strip should turn from black to orange to ensure proper sanitization. The facility's policy and procedure for high-temperature dishwashing machines require that the wash water temperature be no less than specified by the manufacturer, which may vary from 150-165 degrees Fahrenheit, and the final rinse temperature be no less than 180 degrees Fahrenheit. The paper thermometer is expected to change color at 160 degrees Fahrenheit, which reflects 180 degrees Fahrenheit at the manifold where the dish machine's final rinse temperature is measured. However, during the observation, the dishwashing machine did not meet these temperature requirements, leading to a deficiency in ensuring proper sanitization of dishes and utensils.
Failure to Hold Required QAPI Meetings and Ensure Attendance
Penalty
Summary
The facility failed to hold quarterly and as-needed Quality Assurance Performance Improvement (QAPI) committee meetings and did not have the required members in attendance. The facility's QAPI meeting attendance records showed that meetings were held on January 18, 2024, and April 15, 2024, with the previous meeting on July 26, 2023. There was no meeting held between July 26, 2023, and January 18, 2024, missing the required quarterly meeting in October 2023. The facility administrator acknowledged that the October meeting was not scheduled and was not rescheduled for November or December 2023 due to a COVID outbreak affecting 62 residents and 37 staff members. Additionally, there was no evidence of a QAPI meeting held in response to the COVID outbreak. The April 15, 2024, QAPI meeting was also deficient in attendance, as the Medical Director did not attend, and there was no signature indicating their presence. The administrator stated that the Medical Director was on vacation, and their associate did not attend the meeting either. The facility's policy on QAPI emphasizes the importance of continuous and objective measurement of care quality and outcomes, yet the failure to hold required meetings and ensure the presence of key members indicates a lapse in adherence to this policy.
Failure to Offer COVID-19 Vaccine to Residents and Staff
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to residents and staff members, affecting all 250 residents. During interviews and record reviews, it was found that several residents had not been offered or refused further COVID-19 vaccinations since their last recorded doses in October 2022. The facility had been in COVID-19 outbreak status in late 2023, with 37 staff members and 62 residents testing positive. Despite this, there was no documentation indicating that the vaccine had been offered to residents or staff in 2023 or 2024. The Infection Preventionist (IP) stated that while they educate staff and residents about the vaccine, they no longer offer it directly, instead encouraging individuals to use their insurance to get vaccinated independently. There was no tracking of vaccination status for staff or new hires, and no documentation of educational efforts regarding the vaccine. Maintenance staff confirmed they had not been offered the vaccine in two years and had to seek it out independently. The facility provided guidance indicating the importance of vaccination but did not follow through with offering or documenting vaccinations.
Failure to Provide Written Notification of Medicare Part A Termination
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the termination of Medicare Part A services. This deficiency was identified for four residents who were part of a sample review. The facility's records showed that verbal notices were given to guardians or emergency contacts, but there was no documentation of written notices being provided. For instance, one resident with moderately impaired cognition had their Medicare Part A services end without documented notification to their guardian. Similarly, another resident, who was cognitively impaired, also did not receive documented written notification about the end of their Medicare Part A services. The facility's process involved social services notifying families over the phone about the termination of Medicare Part A benefits, but they did not follow up with a certified written notice. This lack of documentation and failure to provide written notices was consistent across all four cases reviewed. The absence of written notification is a critical oversight, as it leaves residents and their representatives uninformed about their coverage status and potential liabilities for services not covered by Medicare.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label, date, and store medications according to professional guidelines, leading to several deficiencies in medication management. Observations revealed that medications such as Dorzolamide Timolol eye drops, Lumigan eye drops, and Lantus Kwik Pen were either not dated upon opening or were expired but not removed from the medication cart. Additionally, medications belonging to residents who were no longer in the facility were not discarded, and some medications lacked proper pharmacy labeling, such as Norco tablets that were only labeled with a handwritten note. Furthermore, insulin storage practices were not adhered to, as unused insulin pens were stored in medication carts instead of being refrigerated as required. Insulin Lispro and Insulin Glargine pens were found in the carts despite labels indicating they should be refrigerated until opened. The Director of Nursing confirmed that staff should label and date insulin, refrigerate unused or new insulin, and ensure narcotics have proper pharmacy labels. These lapses in medication management were observed across multiple residents, indicating a systemic issue in the facility's adherence to medication storage and labeling protocols.
Improper Serving Scoop Sizes Used for Resident Meals
Penalty
Summary
The facility failed to adhere to the prescribed serving scoop sizes for mechanical soft and pureed consistency beef cubed steak as outlined in their menu spreadsheet. During an observation of meal service, it was noted that the cook used a #12 scoop instead of the required #6 scoop for mechanical soft diets, and a #8 scoop instead of the #6 scoop for pureed diets. This discrepancy affected 10 residents who were on these specific diets. The facility's policy and procedure manual clearly indicated the correct scoop sizes to be used, which were not followed during the meal service. The dietitian confirmed that the facility should follow the approved menu spreadsheet, as meals are planned based on specific calorie and nutrition information. The cook assumed that the scoop sizes used provided the correct portion sizes, which was incorrect. The facility's policy also stated that serving portions should be controlled by the use of specified utensils, and the director of food and nutrition services or the person in charge should ensure the correct utensils are used prior to serving. This oversight led to the deficiency in serving the appropriate portion sizes to the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection control practices, as evidenced by multiple observations of staff not performing proper hand hygiene and not using personal protective equipment (PPE) appropriately. For instance, a Certified Nursing Assistant (CNA) did not perform hand hygiene while providing incontinence care to a resident, despite changing gloves between tasks. Additionally, a housekeeper was observed carrying soiled linens without placing them in a plastic bag and failed to remove gloves and wash hands after handling the linens. The facility also did not follow protocols for handling indwelling urinary catheters. Two residents were observed with their catheter drainage bags and tubing lying directly on the floor, contrary to the facility's policy that requires these items to be kept off the floor to prevent infection. One resident's care plan specifically indicated that the drainage bag should be covered and off the floor, yet this was not adhered to. Furthermore, a CNA failed to use a gown as required by the Enhanced Barrier Precaution (EBP) protocol while providing care to a resident with a history of Extended Spectrum Beta-Lactamase (ESBL) in urine. This oversight was attributed to the CNA having been on vacation the previous week and forgetting the protocol. The facility's policy on EBP emphasizes the use of targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms.
Breach of Resident Confidentiality Due to Unattended Laptop
Penalty
Summary
The facility failed to protect a resident's healthcare information from unauthorized view, resulting in a breach of confidentiality. On June 26, 2024, a laptop displaying a resident's Medication Administration Record (MAR) was left open and unattended on a medication cart in the 200 hallway. The screen, which included identifying information, a picture, and medication orders, was visible to anyone passing by, including another resident and facility staff. The unattended laptop was left in this state for approximately ten minutes, during which time a resident sitting in a nearby doorway and two staff members, a Laundry Aide and a Restorative Aide, had the opportunity to view the sensitive information. The resident whose information was exposed, identified as R123, had multiple diagnoses including myasthenia gravis, type 2 diabetes, chronic obstructive pulmonary disease, schizophrenia, and Alzheimer's disease, and was moderately cognitively impaired. The LPN responsible for the medication cart admitted to not knowing how to secure the screen, indicating a lack of training or awareness regarding the facility's confidentiality policy. The facility's policy, dated October 2017, mandates the safeguarding of personal and medical records, limiting access to authorized staff only. This incident highlights a failure to adhere to these policies, compromising the privacy of the resident's medical information.
Failure to Assist Residents with ADLs and Meal Support
Penalty
Summary
The facility failed to provide necessary assistance in grooming and personal hygiene for three residents who required help with activities of daily living (ADLs). One resident, diagnosed with dementia and spinal stenosis, was observed with facial hair despite expressing a desire for its removal. The resident's care plan required staff assistance with grooming, which was not provided. Another resident, also with dementia and additional medical conditions, was found with facial hair and significant oral hygiene issues, including food debris and tartar buildup. The care plan for this resident specified the need for grooming and oral care assistance, which was not adequately delivered. A registered nurse supervisor acknowledged the issues but was unaware of the frequency of dental visits. Additionally, a third resident, who was cognitively impaired and required assistance with eating, was left unattended during meals. This resident was observed using bare hands to eat pureed food, contrary to the facility's policy that mandates staff assistance for residents who cannot feed themselves. Despite the care plan indicating the need for partial staff assistance during meals, the resident was not provided with the necessary support, compromising their dignity and comfort during mealtime.
Inadequate Wound Care for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate wound care for a resident with a stage 4 pressure ulcer, as observed during a survey. On June 25, 2024, wound care nurses noted that the resident's wound dressing was heavily saturated with discharge and had brown discoloration, indicating inadequate care. The resident had multiple pressure ulcers, including a stage 4 ulcer on the sacrum and right buttock, which required daily and as-needed dressing changes. However, the dressing was observed to be almost detached due to the heaviness of the discharge, suggesting that the necessary care was not being provided. Further observations on June 26, 2024, revealed that the dressing was again heavily soiled, despite the Director of Nursing's statement that the dressing should be changed daily and as needed, especially due to the resident's incontinence. The resident's care plan indicated a high risk for skin breakdown due to factors such as advanced age, incontinence, decreased mobility, and malnutrition. The care plan also included interventions to monitor the dressing's condition and report any issues, which were not adequately followed, leading to the deficiency.
Failure to Timely Address Pharmacist Recommendations
Penalty
Summary
The facility failed to timely address recommendations from the pharmacist for two residents reviewed for monthly medication reviews. Resident 1 (R1) was admitted with multiple diagnoses, including dementia and unspecified psychosis, and was prescribed quetiapine and lorazepam. The pharmacist recommended a gradual dose reduction of quetiapine and a stop date for lorazepam, but these recommendations were not promptly addressed. The nurse practitioner eventually discontinued quetiapine and continued lorazepam for 14 days, but the delay in response was noted. The Director of Nursing (DON) admitted to placing the recommendations in the nurse practitioner's mailbox without a specific timeframe for follow-up, leading to a lack of timely action on the pharmacist's recommendations. Resident 2 (R2) had diagnoses including dementia and major depressive disorder and was receiving risperidone. The pharmacist recommended a gradual dose reduction of risperidone, but this recommendation was not submitted to the practitioner by the DON. The pharmacist and the General Manager Pharmacist both highlighted the importance of timely responses to recommendations, but no specific timeframe was provided. The Administrator emphasized that pharmacy recommendations for psychotropics should be communicated to the prescriber immediately, and not left in a mailbox. The facility's policy on Medication Regimen Reviews (MRR) states that the goal is to promote positive outcomes while minimizing adverse consequences. The policy also requires timely and adequate responses to pharmacist recommendations, with escalation to the Medical Director or Administrator if no action is taken. However, the facility failed to adhere to this policy, resulting in delayed responses to pharmacist recommendations for both residents, potentially compromising their care.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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